1. No category

Rocky Mountain
Medicare Covered Benefit Basic Plan (Cost)
You Pay
Monthly Plan Premium
Medical Only
Medical Deductible
Medical out-of-pocket
maximum
Inpatient Hospital
Copayment
Primary Care Physician
Office Visit Copayment
Specialist Care Physician
Office Visit Copayment
Preventive Screening and
Lab Services
$10.00*
*plus you must continue to pay your Medicare Part B premium
For 2016, $166 per calendar year (annual deductible). Costsharing may change in 2017.
There is no Maximum Out-of-pocket on this plan
For 2016, you pay an initial Part A inpatient hospital deductible of
$1,288 which covers days 1-60. You pay $322 for days 61-90, then
$644 for each lifetime reserve day. Cost-sharing may change in
2017.
After you pay the yearly Part B deductible, you pay 20% of the
cost.
After you pay the yearly Part B deductible, you pay 20% of the
cost.
$0
Annual Routine Physical
Not Covered
Emergency Room
After you pay the yearly Part B deductible, you pay 20% of the
cost.
Urgent Care
After you pay the yearly Part B deductible, you pay 20% of the
cost.
Ambulance
After you pay the yearly Part B deductible, you pay 20% of the
cost.
Diagnostic Tests
After you pay the yearly Part B deductible, you pay 20% of the
cost.
Outpatient Surgery
After you pay the yearly Part B deductible, you pay 20% of the cost
at an outpatient hospital facility or ambulatory surgical center for
outpatient surgery.
Skilled Nursing Facility
For 2016, you pay $0 copayment for days 1-20 and $161
copayment for days 21-100. Cost-sharing may change in 2017.
Durable Medical
Equipment
After you pay the yearly Part B deductible, you pay 20% of the
cost.
H0602_MS_MC101Basic_09082016 Accepted
This information is not a complete description of benefits. Contact the plan for more information.
Limitations, copayments, and restrictions may apply.
Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.
This information is available for free in other languages. Please call Customer Service at 888282-1420 (TTY dial 711). Hours are 8am - 8pm, 7 days/week, Oct. 1–Feb.14, and 8am - 8pm,
M-F, Feb.15–Sept.30.
Esta información está disponible gratuitamente en otros idiomas. Por favor llame a la línea de
Atención a Clientes, al 888-282-1420 (TTY marque 711). Horario de 8am - 8pm, 7 días a la
semana, del 1 de octubre al 14 de febrero; y 8am - 8pm, de lunes a viernes, del 15 de febrero
al 30 de septiembre.
RMHP is a Medicare-approved Cost plan. Enrollment in RMHP depends on contract renewal.
H0602_MS_MC101Basic_09082016 Accepted